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A move to collaborative addiction care

November 4, 2009
by A. Tom Horvath
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If collaboration works in individual treatment, why couldn’t it be applied systemwide?

Confrontation remains widely used in U.S. addiction treatment, but produces worse outcomes than empathy does (seewww.behaviortherapy.com/whatworks.htm). Motivational Interviewing (MI) is empathic and collaborative and is a well-established evidence-based treatment (see
http://motivationalinterview.org/clinical/principles.html). MI teaches no particular perspective, teaches no specific skills, and neither suggests, expects, nor demands any particular behaviors. MI appears to work by eliciting motivations for change that are deeper and more powerful than the desire for addictive behavior.

Confrontation makes demands: “You need to believe this about your addiction. You need to do this to overcome it.” Collaboration raises questions: “What is important to you? What would you like to do about it?”

If in individual sessions collaboration is better than confrontation, should we not orient the entire addiction treatment system around collaboration? If we did, how would the system operate?
A new model

In collaborative addiction care there are no fixed lengths of stay, a wide range of service choices, and acceptance of the client’s understanding of his/her addictive behavior, including its causes and effects, and how to change it. The possibility of natural recovery—recovery without formal outside help—would be acknowledged. Treatment would be understood as an adjunct to this naturally occurring process, rather than an essential aspect of it.

If the first call to the treatment system were made by a loved one, concerned that the user/drinker might not be willing to seek treatment, the caller would be informed about Community Reinforcement and Family Training (CRAFT), an evidence-based alternative to Johnson Institute and other interventions (see
www.robertjmeyersphd.com/craft.html). Although not as well-known, CRAFT is three times more effective than intervention in convincing the individual to enter treatment. CRAFT also reduces use substantially, even if the individual does not enter treatment, and the functioning and well-being of family members improves. CRAFT is collaborative. Family members are taught how to reinforce non-use and other positive behaviors. Although CRAFT does not work instantly, it works more often and is less likely to cause harm.

If the first call were from the potential client, the call would be oriented around responding to the client’s concerns. These concerns might be primarily informational: Are there medications I can take? How do I know if I need detox? Are there free services available? Will my insurance cover treatment? What about confidentiality? The outcome of the call would not necessarily be an intake appointment. Rather, the treatment system would be positioning itself as a credible, helpful entity.

If the client were to elect to attend an initial session, this session would occur with a professional trained in both addictive behavior and mental health. Because of high levels of co-occurring mental health disorders as well as relationship concerns—the latter perhaps the most common reason people seek psychotherapy or counseling—a meaningful interview about addictive behavior is likely to include other issues as well.

This initial session would focus on identifying the client’s goals, and how the client benefits (or at least used to benefit) from the addictive behavior. The client also might wish to discuss concerns about engaging in treatment. However, as with the initial phone call, this session might be primarily informational.

If the client were to elect to enter treatment, how would treatment be structured? Although the American Society of Addiction Medicine (ASAM) has guidelines about what level of care clients need, clients often have their own plans regarding the length, intensity, and type of treatment. Consequently, in a collaborative approach, the client’s parameters for treatment would be established. Clients are more likely, however, to have a clearer picture about length and intensity than about type of treatment, particularly if they are new to treatment.
A typical dialogue

One scenario might unfold as follows. The client says, “I can manage the detox on my own; I’ve done it before. I’ll stop drinking Thursday, and hope to be back at work on Monday. I’ll call my doctor, as you suggest, if I need to. I’m not ready to do residential treatment, and furthermore I don’t think I really need it. I’m willing to consider residential if I don’t make enough progress as an outpatient. Actually, I watched my father quit drinking on his own years ago, and I’m imagining something like that process for me. Except that I may not be as strong-willed as he is. So I believe I need to do something every day, at least for a few weeks. Could I have some kind of session every day including Saturday, and see how it goes for a while?”

The intake coordinator might respond, “We will schedule an individual session every day after work, and on Saturday morning so you can have the rest of the day to engage in positive activities. You have no interest in attending groups or support groups, so we’ll skip those. I hope at some point you will consider a group, because it can be enormously enlightening to hear how others are dealing with similar problems. In addition to groups in the office, there are free support groups, both 12-Step groups, and self-empowering groups such as SMART Recovery, which you may not have heard of.